Outcome after partial hepatectomy for hepatocellular cancer within the Milan criteria.

BACKGROUND: There is a trend to offer liver transplantation to patients with hepatocellular carcinoma (HCC) with tumour status within the Milan criteria but with preserved liver function. This study aimed to evaluate the outcome of such patients following partial hepatectomy as primary treatment. METHODS: A retrospective analysis was performed on all adult patients with HCC and tumour status within the Milan criteria undergoing partial hepatectomy at a single centre from 1995 to 2008. Their outcomes were compared with those of similar patients having right-lobe living donor liver transplantation (LDLT) as primary treatment. RESULTS: A total of 408 patients with HCC were enrolled. Some 384 patients with a solitary tumour 5 cm or less in diameter had a better 5-year survival rate than 24 patients with oligonodular tumours (2-3 nodules, each 3 cm or less in size) (70·7 versus 46 per cent; P = 0·025). Multivariable analysis identified younger age (65 years or less), lack of postoperative complications, negative resection margin, absent microvascular invasion and non-cirrhotic liver as predictors of favourable overall survival. The 5-year survival rate of 287 younger patients with chronic liver disease and R0 hepatectomy was 72·8 per cent, comparable to that of 81 per cent in 50 similar patients treated by LDLT (P = 0·093). CONCLUSION: Partial hepatectomy for patients with HCC and tumour status within the Milan criteria achieved a satisfactory 5-year survival rate, particularly in younger patients with solitary tumours and R0 hepatectomy. Patients with oligonodular tumours have a worse survival and might benefit from liver transplantation.

The first 5 years since trauma center designation in the Hong Kong Special Administrative Region, People's Republic of China.

BACKGROUND: In 1994, the Hong Kong Special Administrative Region (HKSAR) introduced plans to implement a trauma system based on the recommendations outlined by Professor Donald Trunkey in his report to the local Hospital Authority. Five government-subsidized public hospitals were subsequently designated as trauma centers in 2003. This article reviews the initial experience in these five centers. METHODS: Prospective trauma registries from January 2004 to December 2008 were reviewed. Primary clinical outcome measures were hospital mortality. The Trauma and Injury Severity Score methodology was used for benchmarking with the Major Trauma Outcome Study (MTOS) database. RESULTS: The majority (83.3%) of the 10,462 patients suffered from blunt trauma. Severe injury, defined as Injury Severity Score>15, occurred in 29.7% of patients. The leading causes of trauma were motor vehicle collisions and falls, with crude hospital mortality rates of 6.9% and 10.7%, respectively. The M-statistic was 0.95, indicating comparable case-mix with the MTOS. The worst outcome occurred in the first year. Significant improvement was seen in patients with penetrating injuries. By 2008, these patients had significantly higher survival rates than expected (Z-statistic=0.85). Although the overall mortality rates for blunt trauma were higher than expected, the difference was no longer statistically significant from the second year onward. CONCLUSIONS: The case-mix of trauma patients in the HKSAR is comparable with that of the MTOS. A young trauma system relatively unburdened by dissimilar reimbursement and patient access issues may achieve significant improvement and satisfactory patient outcomes. Our findings may serve as a useful benchmark for HK and other Southeast Asian cities and trauma systems to establish local coefficients for future evaluations.

Telephone pre-anaesthesia assessment for ambulatory breast surgery.

OBJECTIVE: To review the efficacy of telephone preoperative anaesthesia assessment in patients undergoing ambulatory breast surgery. DESIGN: Retrospective study. SETTING: Day Surgery Centre, Tung Wah Hospital, Hong Kong. PATIENTS: Patients with breast lumps to be excised were seen by dedicated breast surgeons and informed of day procedures and preoperative anaesthesia assessment. Those who fulfilled the selection criteria of age (18-45 years) and American Society of Anesthesiologists grade I were recruited for telephone anaesthesia assessment preoperatively. The patients were contacted by senior day surgery nurses via telephone before the scheduled operation date, and information was retrieved using a standard assessment form. Prospective data from January 2002 to December 2007 were analysed. MAIN OUTCOME MEASURES: Proportion of patients who successfully underwent day surgery after telephone preoperative anaesthesia assessment. RESULTS: Of 482 patients receiving ambulatory surgery for breast lumps during the study period, 283 patients were selected for preoperative telephone anaesthesia assessment. Five (2%) patients with problems identified by this method underwent further assessment at the Day Surgery Centre; the remaining 278 (98%) required no further assessment and proceeded to have a successful day surgery procedure. CONCLUSION: Preoperative anaesthesia assessment by telephone is an effective means of preoperative assessment in selected patients undergoing ambulatory breast surgery.

Day surgery varicose vein treatment using endovenous laser.

OBJECTIVE: To examine the safety and efficacy of endovenous laser obliteration to treat varicose vein in a day surgery setting, using sedation and local anaesthesia. DESIGN: Prospective study. SETTING: Day surgery centre in a regional hospital in Hong Kong. PATIENTS: A total of 24 patients with duplex-confirmed long saphenous vein insufficiency underwent endovenous laser (940 nm) varicose vein treatment from July to November 2007 in a single day surgery centre. Adjuvant phlebectomy and injection sclerotherapy were performed in the same session if indicated. All patients had postprocedural venous duplex scan and clinic assessment on day 7 and day 10 respectively. MAIN OUTCOME MEASURES: Procedure success rate, unplanned hospital admissions and re-admissions, major complications, and long saphenous vein obliteration rate. RESULTS: A total of 31 limbs of the 24 patients were treated with endovenous laser varicose vein treatment under local anaesthesia and sedation. The procedural success rate was 100%. All but two patients were admitted on the day of treatment and none were re-admitted. The patients' mean visual analogue pain score for the whole procedure was 2.3 (standard deviation, 1.5; range, 0-5). Post-procedural duplex scans showed 100% thrombosis of the treated long saphenous veins with no deep vein thrombosis. There were no skin burns or instances of thrombophlebitis. Induration of the treated long saphenous vein was relatively common (54%). The majority of the patients (54%) experienced mild discomfort in the early postoperative period. CONCLUSION: Endovenous laser varicose vein treatment performed under local anaesthesia and sedation in a day surgery setting is safe, and yields satisfactory clinical and duplex outcomes.

High risk trauma in older adults in Hong Kong: a multicentre study.

BACKGROUND: Trauma is the eighth leading cause of death in Hong Kong. In 2002, 18.5% of the population of Hong Kong was aged 55 years or above, which increased to 22.1% in 2006. The increasing older population in Hong Kong presents a challenge to the health care system yet there is little local data on older trauma patients. The objectives of this study are firstly to describe the epidemiology of high risk trauma in older patients in Hong Kong, and secondly to identify predictors of trauma mortality. METHOD: Retrospective analysis of prospectively collected data from a centralised trauma database; data collected from 2002 to 2004 from four trauma centres in Hong Kong. RESULTS: Between 2002 and 2004, the four trauma centres had a total of 2,124,175 emergency department attendances of which 376,021 (17.7%) were trauma patients, and 80,827 (3.8%) were aged 55 years or older. 810 injured older patients met the inclusion criteria for this study. 380 (46.9%) patients had co-morbidity at the time of injury. Common causes of injury were falls (50.0%, 405/810) and motor vehicle crashes (33.6%, 272/810) of which (77.2%, 210/272) were pedestrians. Mortality was 24.4% (198/810) and increased with advancing age (p<0.0001). 53.5% (433/810) of patients had major trauma (ISS>15). Head injury contributed to 80.3% (159/198) of deaths. 38.4% (311/810) of patients required operations. Most patients were discharged home (40.5%, 328/810) and one-third (270/810) required rehabilitation. Significant predictors of mortality included co-morbidity, injury severity score, age and decreasing Glasgow Coma Score. CONCLUSION: Pedestrians struck by motor vehicles and falls are the principal causes of trauma in older patients in Hong Kong. Mortality increased with advancing age. The independent indicators of trauma mortality in older patients are co-morbidity, age, ISS and GCS.

Management of herniated retroperitoneal adipose tissue during endoscopic extraperitoneal inguinal hernioplasty.

BACKGROUND: Herniation of retroperitoneal adipose tissue into the inguinal canal, traditionally called cord lipoma, is frequently encountered during endoscopic totally extraperitoneal inguinal hernioplasty (TEP). Failure to recognize and manage the cord lipoma accounted for 30%-50% of recurrent hernia after TEP. The present study was undertaken to evaluate the incidence, risk factors, and management of herniated retroperitoneal adipose tissue during TEP. METHODS: Between December 2002 and November 2005 all patients who underwent TEP were prospectively evaluated for the presence of cord lipoma. Clinical outcomes of patients who were treated for their cord lipoma were compared with those without cord lipoma. Risk factors for the occurrence of cord lipoma were also examined. RESULTS: A total of 498 patients underwent unilateral (n = 386) or bilateral (n = 112) TEP. The overall incidence of cord lipoma was 26.5% (n = 132). A higher body weight, a higher body mass index, and a larger hernial defect were significantly associated with the presence of cord lipoma. Most of the cord lipoma cases (n = 119) were reduced to pelvic peritoneal reflection line after division of the feeding vessels from surrounding structures, while the rest (n = 13) were resected. Early postoperative outcomes, including pain score, morbidities, and other recovery variables, showed no significant difference between the two groups. No recurrence occurred in the present series. CONCLUSIONS: Herniation of retroperitoneal adipose tissue into the inguinal canal occurred in more than one-fifth of the patients with inguinal hernia. Awareness and appropriate treatment of the cord lipoma helped to reduce the risk of recurrence. During TEP, the internal inguinal ring and inguinal canal should always be cleared of any herniated adipose tissue by either reduction or resection. This clearing posed no adverse effects on postoperative outcome.

Primary large B-cell lymphoma of the ampulla of Vater.

Primary lymphoma of the ampulla of Vater is rare. The clinico-pathological and interesting endoscopic and radiological features of a patient with this disorder is presented.

Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial.

BACKGROUND: Endoscopic totally extraperitoneal inguinal hernioplasty (TEP) is an accepted technique for the repair of recurrent and bilateral inguinal hernia, but its role in the management of unilateral primary inguinal hernia remains controversial. The current randomized trial was undertaken to compare the postoperative and 1-year outcomes of day-case TEP and open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males. METHODS: From January 2002 to January 2004, a total of 200 male patients were randomized to undergo either day-case unilateral TEP or open Lichtenstein hernioplasty under general anesthesia. The primary outcome measures included postoperative pain score, time until return to work, incidence of chronic groin pain, and recurrence rate 1 year after the operation. RESULTS: All TEP procedures were successfully performed without conversion. The mean operation time for TEP (50 +/- 13.2 min) was significantly shorter than for open Lichtenstein hernioplasty (58 +/- 17.6 min) (p < 0.001). The pain score at rest was significantly lower in the TEP group than in the open group on postoperative days 0, 1, 4, 5, and 6. On the average, the patients returned to work 8.6 days after TEP and 14 days after Lichtenstein hernioplasty (p = 0.006). Postoperative recovery and morbidity rates were otherwise comparable between the two groups. The incidence of chronic groin pain 1 year after TEP (9.9%) was significantly lower than after open surgery (21.7%) (p = 0.032). None of the patients in either group showed recurrence at the last follow-up assessment. CONCLUSIONS: Day-case TEP was superior to open Lichtenstein hernioplasty for the repair of unilateral primary inguinal hernia in males. The benefits of day-case TEP included less postoperative pain, a faster return to work, and a lower incidence of chronic groin pain.

Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis.

BACKGROUND: Early laparoscopic cholecystectomy has been advocated for the management of acute cholecystitis, but little evidence exists to support the superiority of this approach over delayed-interval operation. The current systematic review was undertaken to compare the outcomes and efficacy between early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis in an evidence-based approach using metaanalytical techniques. METHODS: A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1988 and June 2004. Only randomized or quasi-randomized prospective clinical trials in the English language comparing the outcomes of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were recruited. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where feasible and appropriate. RESULTS: A total of four clinical trials comprising 504 patients met the inclusion criteria. Failure of conservative treatment requiring emergency cholecystectomy occurred for 43 patients (23%) in the delayed group. Metaanalyses demonstrated a significantly shortened total length of hospital stay in the early group (weighted mean difference, -1.12; 95% confidence interval [CI], -1.42 to -0.99; p < 0.001). Pooled estimates did not show any significant differences between the two approaches in terms of operation time, conversion rate, overall complication rate, incidence of bile leakage, and intraabdominal collection. CONCLUSIONS: The safety and efficacy of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were comparable. Because evidence suggested that early laparoscopic cholecystectomy reduced the total length of hospital stay and the risk of readmissions attributable to recurrent acute cholecystitis, it is therefore a more cost-effective approach for the management of acute cholecystitis.

Is endoscopic totally extraperitoneal hernioplasty justified for the repair of groin hernia in female patients?

BACKGROUND: Groin hernia is an uncommon surgical pathology in females. The efficacy of the endoscopic approach for the repair of female groin hernia has yet to be examined. The current study was undertaken to compare the clinical outcomes of female patients who underwent open and endoscopic totally extraperitoneal inguinal or femoral hernioplasty (TEP). METHODS: From July 1998 to June 2004, 108 female patients who underwent elective repair of groin hernia were recruited. The patients were divided into TEP (n = 30) and open groups (n = 78) based on the type of operation. Clinical data and outcome parameters were compared between the two groups. RESULTS: The mean ages and hernia types were comparable between the two groups. All TEPs were successfully performed. The mean operative times were 52 min for unilateral TEP and 51 min for open repair. The difference was not statistically significant. Comparisons of the length of hospital stay, postoperative morbidity, pain score, and time taken to resume normal activities showed no significant differences between the two groups. A single patient in the TEP group experienced recurrence of hernia. CONCLUSIONS: The findings show equivalent postoperative outcomes after TEP and open repair of groin hernia in female patients. Because the wound scar after open repair is well concealed beneath the pubic hair and no superior clinical benefits are observed after TEP, open repair appears to be the technique of choice for the management of primary groin hernia in females. The TEP approach should be reserved for female patients with recurrent or multiple groin hernia.

Significance of the Hygiene Charter towards different sectors in Hong Kong.

The occurrence of SARS in March 2003 has resulted in an increased interest, worldwide in emerging infectious diseases. The SARS experience provided us a lesson on the importance of promoting hygienic practices among individuals and different working sectors. In Hong Kong, a voluntary organization called the UNITE proposed a Hygiene Charter which aimed at taking hygiene to new levels. This action has been supported by individuals and different sectors including the Personal and Family, Management, Buildings, Catering, Education, Finance and Commercial, Industrial, Medical and Health, Public Transportation, Social Welfare, Sports and Culture and Tourism. As promotion and maintenance of environmental health requires input from different sectors, the signing of the Hygiene Charter provides an opportunity for individuals and the public to show their pledge and commitment to good hygiene practices. As a result, with environment improvement and good infectious disease control measures, prevention of epidemics of infectious diseases is deemed to be possible.

Parent training: experience of the New Territories West School Health Promotion Project of Hong Kong.

Parents' participation in school life is an important element of a health-promoting school. To maximize the potential of parents as partners in health education and take on a leading role in promoting health in the school, family and community, a parental health education programme using the empowerment model had been launched in partnership between academic and health sectors. A total of 28 parents selected from eight schools in the New Territories West region of Hong Kong participated in the programme. Evaluation of the programme revealed that the programme had matched well with the expectation of most participants. All respondents had reported an increase in health awareness and knowledge, and confidence to promote health concepts in familiar environments, such as the home and school. They also showed interest to participate in further training in health related issues. Parental health education is recommended to enhance active involvement for building a greater sense of belonging and to put through individual empowerment to community empowerment. Parental involvement in school health promotion would be an effective way to facilitate the paradigm shift.

Intravenous bolus somatostatin after diagnostic cholangiopancreatography reduces the incidence of pancreatitis associated with therapeutic endoscopic retrograde cholangiopancreatography procedures: a randomised controlled trial.

BACKGROUND: Previous studies suggested that somatostatin given before endoscopic retrograde cholangiopancreatography (ERCP) may reduce the incidence of post-ERCP pancreatitis. However, the routine use of somatostatin in all patients undergoing ERCP is not likely to be cost effective. This study evaluated whether intravenous bolus somatostatin given after diagnostic cholangiopancreatography could reduce the incidence of pancreatitis in a group of patients undergoing therapeutic ERCP procedures. METHODS: In a randomised, double blind, controlled trial, the effect of intravenous bolus somatostatin 250 microg given immediately after diagnostic cholangiopancreatography was compared with that of placebo in patients who required endoscopic sphincterotomy or other therapeutic procedures. The primary end point was the incidence of post-ERCP clinical pancreatitis, and a secondary end point was the incidence of hyperamylasemia. RESULTS: A total of 270 patients were randomised. The somatostatin group (n=135) and the placebo group (n=135) were comparable in age, sex, indications for treatment, and types of procedure. The frequencies of clinical pancreatitis (4.4% v 13.3%; p=0.010) and hyperamylasemia (26.0% v 38.5%; p=0.036) were both significantly lower in the somatostatin group compared with the placebo group. CONCLUSIONS: A single dose of intravenous bolus somatostatin, given immediately after diagnostic cholangiopancreatography, is effective in reducing the incidence of pancreatitis after therapeutic ERCP. This novel approach of administering prophylactic somatostatin may offer a cost effective prophylaxis for post-ERCP pancreatitis.

Prevalence and severity of chronic groin pain after endoscopic totally extraperitoneal inguinal hernioplasty.

BACKGROUND: Chronic groin pain after open inguinal hernia repair is a common long-term morbidity, but its incidence after endoscopic totally extraperitoneal inguinal hernioplasty (TEP) has not been studied in detail. The objective of this study was to evaluate the prevalence and severity of chronic groin pain after TEP. METHODS: Between June 1999 and September 2001, 313 consecutive patients who underwent TEP at our institution were recruited. To evaluate the incidence and severity of chronic pain, a cross-sectional telephone survey using a standardized questionnaire was conducted by a research assistant. Clinical data between the chronic pain group and the pain-free group were compared to identify any clinical factors that had a significant association with the subsequent development of chronic groin pain. RESULTS: The prevalence of chronic groin pain was 9.2% ( n = 24). The severity of the pain was mild ( n = 18), moderate ( n = 5), or severe ( n = 1). In more than half of the patients, the groin pain occurred less often than once a month and its duration did not exceed 1 min. Only one patient reported an impairment of functional activities as a result of the pain. Multivariate analyses identified a significant association between a high postoperative pain score on coughing on postoperative day 6 and the subsequent development of groin pain. CONCLUSIONS: The prevalence of chronic groin pain in patients after TEP was low. The pain was mostly mild and transient without associated sensory symptoms. The occurrence of pain had a negligible impact on daily activities.

Laparoscopic incisional hernioplasty utilising on-lay expanded polytetrafluoroethylene DualMesh: prospective study.

OBJECTIVE: To evaluate the early outcomes of laparoscopic incisional hernioplasties using on-lay GORE-TEX DualMesh. DESIGN: Prospective study. SETTING: Medical centre of a regional hospital, Hong Kong. SUBJECTS AND METHODS: Between June 2000 and October 2001, 11 consecutive patients underwent attempted laparoscopic incisional hernioplasties at the University of Hong Kong Medical Centre. A prospective collection of perioperative data and assessment of postoperative outcomes was performed. RESULTS: Laparoscopic incisional hernioplasty was successfully performed for 10 (91%) patients. One patient was converted to open repair because of extensive adhesions within the peritoneal cavity. The overall mean operative time was 107 minutes. Five (45%) patients were found to have more than one hernial defect after reduction of the hernial contents. Eight (73%) patients were discharged within 2 days after operation. Postoperative morbidities included wound bruising (n=4), seroma (n=2), and prolonged suture site pain (n=1). All postoperative morbidities resolved spontaneously without intervention. With a mean follow-up of 3 months, no early recurrence was detected. CONCLUSION: Early outcomes of laparoscopic incisional hernioplasty utilising GORE-TEX DualMesh were promising. This technique confers the advantages of minimal access surgery and allows clear identification of multiple hernial defects. Extensive adhesion, which does not allow the establishment of pneumoperitoneum, is a condition that precludes the safe performance of laparoscopic repair.

Learning curve for unilateral endoscopic totally extraperitoneal (TEP) inguinal hernioplasty.

BACKGROUND: Performance of endoscopic totally extraperitoneal inguinal hernioplasty (TEP) requires specialized anatomical knowledge and surgical dexterity. The present study was undertaken to evaluate the learning curve for a general surgeon to master the technique of TEP in the absence of an experienced supervisor. METHODS: A retrospective analysis of the first 120 consecutive unilateral TEPs was performed. Medical records were reviewed to evaluate demographic features, perioperative outcome, and follow-up results. The study population was divided into six consecutive groups of 20 patients. Clinical data were compared among the groups to evaluate the impact of operative experience on perioperative outcome. RESULTS: Operative time was the only clinical parameter that showed significant improvement with experience; it reached a plateau value of <1 h after the fourth group. Conversions to transabdominal and open approaches were required in only one patient in groups 1 and 6, respectively. Comparison of demographic features, hernia types, postoperative morbidity rates, length of hospital stay, and number of days to resume normal activities showed no significant differences among the groups. All complications were minor and resolved uneventfully. No recurrence was detected during follow-up. CONCLUSIONS: The learning curve for unilateral TEP by a general surgeon peaked after performing 80 procedures. In most cases, unilateral TEP can be accomplished safely within 1 h. Even during the learning process, TEP carries a low morbidity and conversion rate.

Urinary retention following endoscopic totally extraperitoneal inguinal hernioplasty.

BACKGROUND: The impact of preperitoneal mesh after endoscopic totally extraperitoneal inguinal hernioplasty (TEP) on voiding function has not been previously examined. The objectives of the present study were to evaluate the incidence of and risk factors for urinary retention following TEP. METHODS: Three hundred consecutive patients who underwent TEP between June 1999 and September 2001 were recruited. Patient records were reviewed retrospectively to identify those who developed postoperative urinary retention. For each case patient, five age-matched control patients were randomly selected. We then compared the clinical data for the case and control groups. A prospective study of uroflowmetry in patients who underwent bilateral TEP was conducted to evaluate the effect of preperitoneal mesh on voiding function. RESULTS: The overall incidence of urinary retention following TEP was 4% (n = 12). Patients who developed urinary retention stayed in hospital for a significantly longer period than the control group. No significant association was found between the clinical data and postoperative urinary retention. Bilateral TEPs were not associated with significant deterioration in uroflowmetry. CONCLUSIONS: Urinary retention is a frequent morbidity after TEP and significantly prolongs the length of hospital stay. Preperitoneal Prolene mesh did not cause outflow obstruction or alter bladder contractility. No specific clinical factors were identified that might predict postoperative urinary retention, which was probably multifactorial in causation in our patient population.

Management of peritoneal tear during endoscopic extraperitoneal inguinal hernioplasty.

BACKGROUND: Peritoneal tear during endoscopic extraperitoneal inguinal hernioplasty (TEP) results in pneumoperitoneum and loss of extraperitoneal space. To avoid bowel adhesions, internal herniation, and mesh migration, closure of the peritoneal opening is preferred. The present study was conducted to evaluate the efficacy of various operative techniques for the closure of peritoneal laceration. METHODS: Between April 2000 and May 2001, 100 consecutive patients undergoing 123 TEPs were recruited for the present study. The incidence of peritoneal tear and techniques for the closure of peritoneal opening were documented. Operative time and postoperative morbidity were compared among groups for which different closure methods of peritoneal laceration were used. RESULTS: The incidence of peritoneal tear was 47%. The mean operative times of unilateral TEPs with and without peritoneal laceration were 66 min and 53 min, respectively (p<0.05). Techniques for the closure of the peritoneal opening included endoscopic stapling (n = 12), endoscopic suturing (n = 14), and pretied suture loop ligation (n = 21). The mean operative times for unilateral TEPs with endoscopic stapling, pretied suture loop ligation, and endoscopic suturing of peritoneal tear were 53, 64, and 82 min, respectively (p<0.05). Comparison of postoperative morbidity showed no significant differences among the three groups. CONCLUSION: Peritoneal tear is a frequent and challenging intraoperative event during TEP. Its occurrence significantly prolongs the length of operation. Endoscopic stapling and pretied suture loop ligation are safe and quick techniques for the closure of peritoneal tear during TEP.

A prospective trial of analgesia following endoscopic totally extraperitoneal (TEP) inguinal hernioplasty.

BACKGROUND: The extraperitoneal instillation of bupivacaine has been shown to be superior to the use of a placebo for postoperative analgesia following endoscopic extraperitoneal inguinal hernioplasty. The objective of the present study was to compare the efficacy of postoperative analgesia by local wound infiltration to instillation of the extraperitoneal space with bupivacaine. METHODS: Between 1 September 1999 and 2 June 2000, a total of 100 patients who underwent unilateral endoscopic extraperitoneal inguinal hernioplasties were recruited to receive either local wound infiltration with 10 ml of 0.5% bupivacaine (group I, n = 50) or instillation of the extraperitoneal space with 40 ml of 0.25% bupivacaine after mesh placement (group II, n = 50). Daily postoperative pain was assessed by visual analogue pain score on a scale from 0 to 10 at rest and upon coughing. Total amount of oral analgesic consumed and clinical outcomes of the two groups were compared. RESULTS: A comparison of daily pain scores of the two groups at rest and upon coughing showed no significant difference (p = ns). The mean number of oral analgesic tablets consumed were 3.2 +/- 0.5 (SEM) and 3.3 +/- 0.5 (SEM) in groups I and II, respectively (p = ns). During follow-up, asympatomatic groin collections were more common in group II (n = 4) than group I (n = 2) (p = ns). CONCLUSIONS: Compared to local wound infiltration with bupivacaine, the extraperitoneal instillation of bupivacaine did not bestow any additional analgesic benefits. Therefore, the routine infiltration of skin incisions with bupivacaine is recommended after endoscopic extraperitoneal inguinal hernioplasty.

Purification and characterization of multiple glutathione S-transferase isozymes from Chironomidae larvae.

Glutathione S-transferase (GST) has been implicated in the process of biotransformation of polycyclic aromatic hydrocarbons and of other organic pollutants by Chironomidae larvae. We have purified and characterized GST from cytosolic fractions of Chironomidae larvae. GST with an M(r) of 23 kDa has been purified to homogeneity from larvae by centrifugation, size exclusion chromatography on Sephadex G25, and glutathione affinity and anion exchange chromatography. The purified enzyme exhibited moderate activity towards 1,2-dichloro-4-nitrobenzene, 1-chloro-2,4-dinitrobenzene, 4-nitropyridine-N-oxide, p-nitrobenzyl chloride, ethacrynic acid, and cumene hydroperoxide. The enzyme was homogeneous on gel isoelectric focusing and on SDS gel electrophoresis. Its isoelectric point was estimated to be 5.5. The enzyme had a maximum activity at approximately pH 8 and showed activity between 30 and 40 degrees C. It became inactive at higher temperature (>50 degrees C) for 5 min. The N-terminal sequence analysis of the amino acids shows a high % of conserved regions in the enzyme. The enzyme activity was comparable to levels of metabolism observed by animal GST involved in the detoxification of xenobiotics.